2. Abdominal Trauma
• Penetrating Abdominal Trauma
– Stabbing 3x more common than firearm wounds
– Most commonly injured organs: small intestine > colon > liver
• Blunt Abdominal Trauma
– Greater mortality than PAT (more difficult to diagnose,
commonly associated with trauma to multiple organs/systems)
– Most commonly injured organs: spleen > liver, intestine is the
most likely hollow viscus
Rosen’s Emergency Medicine, 7th ed. 2009
3. Pathophysiology of injury
Penetrating Abdominal Trauma
• Stab Wounds
– Knives, ice picks, pens, coat
hangers, broken bottles
– Liver, small bowel, spleen
• Gunshot wounds
– small bowel, colon and liver
– Often multiple organ injuries,
bowel perforations
Rosen’s Emergency Medicine, 7th ed. 2009
5. Pathophysiology of injury
Blunt Abdominal Trauma
• Rupture or burst injury of a hollow organ by sudden rises in
intra-abdominal pressures
• Crushing effect
• Acceleration and deceleration forces → shear injury
• Seat belt injuries
– “seat belt sign” = highly correlated with intraperitoneal
injury
Rosen’s Emergency Medicine, 7th ed. 2009
6. Physical Exam
• Generally unreliable due to e.g.: spinal cord injury
• Look for signs of intraperitoneal injury
– abdominal tenderness, peritoneal irritation,
gastrointestinal hemorrhage, hypovolemia, hypotension
– entrance and exit wounds to determine path of injury.
– Distention - pneumoperitoneum, gastric dilation, or ileus
– Ecchymosis of flanks (Gray-Turner sign) or umbilicus
(Cullen's sign) - retroperitoneal hemorrhage
– Abdominal contusions
– ↓bowel sounds suggests intraperitoneal injuries
– DRE: blood
Rosen’s Emergency Medicine, 7th ed. 2009
7. Diagnostic studies
• Lab tests: not very helpful
• May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase, tox
screen
Rosen’s Emergency Medicine, 7th ed. 2009
9. Imaging
• CT
– Accurate for solid visceral lesions and intraperitoneal hemorrhage
– guide nonoperative management of solid organ damage
– IV not oral contrast
Rosen’s Emergency Medicine, 7th ed. 2009
10. Imaging
• Angiography
– To embolize bleeding vessels or solid visceral hemorrhage
from blunt trauma in an unstable pt
– Rarely for diagnosing intraperitoneal and retroperitoneal
hemorrhage after penetrating abdominal trauma
Rosen’s Emergency Medicine, 7th ed. 2009
11. FAST
• Focused assessment with sonography for trauma (FAST)
– To diagnose free intraperitoneal blood after blunt trauma
– 4 areas:
• Perihepatic & hepato-renal space (Morrison’s pouch)
• Perisplenic
• Pelvis (Pouch of Douglas/rectovesical pouch)
• Pericardium (subxiphoid)
– sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid
• Extended FAST (E-FAST):
– Add thoracic windows to look for pneumothorax.
– Sensitivity 59%, specificity up to 99% for PTX
Trauma.orgRosen’s Emergency Medicine, 7th ed. 2009
14. FAST
• Retrovesicle (Pouch of Douglas)
• Pericardium (subxiphoid)
trauma.orgRosen’s Emergency Medicine, 7th ed. 2009
15. FAST
• Advantages:
– Portable, fast (<5 min),
– No radiation or contrast
– Less expensive
• Disadvantages
– Not as good for solid parenchymal damage, retroperitoneum,
or diaphragmatic defects.
– Limited by obesity, substantial bowel gas, and subcut air.
– Can’t distinguish blood from ascites.
– high (31%) false-negative rate in detecting hemoperitoneum
in the presence of pelvic fracture
Rosen’s Emergency Medicine, 7th ed. 2009
16. Diagnostic Peritoneal Lavage
• Largely replaced by FAST and CT
• In blunt trauma, used to triage pt who is HD unstable
and has multiple injuries with an equivocal FAST
examination
• In stab wounds, for immediate dx of
hemoperitoneum, determination of intraperitoneal
organ injury, and detection of isolated diaphragm
injury
Rosen’s Emergency Medicine, 7th ed. 2009
17. Diagnostic Peritoneal Lavage
• 1. attempt to aspirate free peritoneal blood
– >10 mL positive for intraperitoneal injury
• 2. insert lavage catheter by seldinger, semiopen, or
open
• 3. lavage peritoneal cavity with saline
• Positive test:
– In blunt trauma, or stab wound : RBC count >
100,000/mm3
Rosen’s Emergency Medicine, 7th ed. 2009
18. Local Wound Exploration
• To determine the depth of penetration in stab
wounds
• If peritoneum is violated, must do more diagnostics
• Preop, extend wound, carefully examine (No blind
probing)
• Indicated for anterior abdominal stab wounds, less
clear for other areas
Rosen’s Emergency Medicine, 7th ed. 2009
19. Laparoscopy
• Most useful to eval penetrating wounds to
thoracoabdominal region in stable pt
– esp for diaphragm injury: Sens 87.5%, specificity 100%
• Can repair organs via the laparoscope
– diaphragm, solid viscera, stomach, small bowel.
• Disadvantages:
– poor sensitivity for hollow visceral injury, retroperitoneum
– Complications from trocar misplacement.
– If diaphragm injury, PTX during insufflation
Rosen’s Emergency Medicine, 7th ed. 2009
20. Management
• General trauma principles:
– airway management, 2 large bore IVs, cover penetrating
wounds and eviscerations with sterile dressings
• Prophylactic antibiotics: decrease risk of intra-
abdominal sepsis due to intestinal perf/spillage
– (eg zosyn 3.375 g IV)
• In general, leave foreign bodies in and remove in the
OR
Rosen’s Emergency Medicine, 7th ed. 2009
22. Management of penetrating abdominal
trauma
• Mandatory laparotomy
vs
• Selective nonoperative management
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
23. Management of penetrating abdominal
trauma
• Mandatory laparotomy
– standard of care for abdominal stab wounds until 1960s,
for GSWs until recently
– Now thought unnecessary in 70% of abdominal stab
wounds
– Increased complication rates, length of stay, costs
– Immediate laparotomy indicated for shock, evisceration,
and peritonitis
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
24. Management of penetrating abdominal
trauma
• Selective management used to reduce unnecessary
laparotomies
• Diagnostic studies to determine if there is
intraperitoneal injury requiring operative repair
• Strategy depends on abdominal region:
– Thoracoabdomen
• Nipple line to costal margin
– Anterior abdomen
• Xiphoid to pubis
– Flank and back
• Posterior to anterior axillary line
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
26. Management of Blunt abdominal trauma
• Exam less reliable
• Diagnostic studies to determine if there is
hemoperitoneum or organ injury requiring surgical
repair
– FAST, CT, DPL
– In HD stable pts, CT is preferred
Rosen’s Emergency Medicine, 7th ed. 2009
27. Management of Blunt abdominal trauma
• Clinical Indications for Laparotomy after Blunt Trauma
MANIFESTATION PITFALL
Unstable vital signs with strongly
indicated abdominal injury
Alternative sources, shock
Unequivocal peritoneal irritation Unreliable
Pneumoperitoneum
Insensitive; may be due to
cardiopulmonary source or invasive
procedures (diagnostic peritoneal
lavage, laparoscopy)
Evidence of diaphragmatic injury Nonspecific
Significant gastrointestinal bleeding Uncommon, unknown accuracy
Rosen’s Emergency Medicine, 7th ed. 2009
28. Damage Control
• Patients with major exsanguinating injuries may not
survive complex procedures
• Control hemorrhage and contamination with
abbreviated laparotomy followed by resuscitation
prior to definitive repair
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
29. Damage Control
• 0. initial resuscitation
• 1. Control of hemorrhage and contamination
– Control injured vasculature, bleeding solid organs
– Abdominal packing
• 2. back to the ICU for resuscitation
– Correction of hypothermia, acidosis, coagulopathy
• 3. Definitive repair of injuries
• 4. Definitive closure of the abdomen
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
30. Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
31. Damage Control
Resuscitation in the ICU
• IVF (crystalloid, not colloid)
• Transfusion
-PRBC/plt/FFP
• Recombinant activated factor VII
– Increased thromboembolic complications
• Rewarming if hypothermic
• Correction of metabolic abnormalities
• Low tidal volume ventilation recommended (4-6 ml/kg)
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
32. Damage Control
Open abdominal wounds and definitive closure
• 40-70% can’t have primary closure after definitive repair.
• Temporary closure methods
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
33. Abdominal Compartment Syndrome
• Common problem with abdominal trauma
• Definition: elevated intraabdominal pressure (IAP) of
≥20 mm Hg, with single or multiple organ system
failure
– ± APP below 50 mm Hg
• Primary ACS: associated with injury/disease in
abdomen
• Secondary (“medical”) ACS: due to problems outside
the abdomen (eg sepsis, capillary leak)
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
35. Abdominal Compartment Syndrome
• Effects of elevated IAP
– Renal dysfunction
– Decreased cardiac output
– Increased airway
pressures and decreased
compliance
– Visceral hypoperfusion
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
36. Abdominal Compartment Syndrome
• Management
– Surgical abdominal decompression
– Nonsurgical: paracentesis, NGT, sedation
– Staged approach to abdominal repair
– Temporary abdominal closure
Sugrue M. Curr Opin Crit Care 2005; 11:333-338Bailey J. Crit Care 2000, 4:23–29
37. -A 22 Ys old male presented to our ER by paramedics after motor
bicycle crash into a tree to the Lt. side of his trunk. At time of
trauma his BP was 100/70 , pulse 114 /min., RR 18/ min., GLCS
14 as regard to paramedics report. In ER he became drowsy and
start deteriorating. In ER his BP was 60/45 , pulse 135 /min., RR
32/ min., GLCS 11. 1ry survey reveals intact airway, tenderness
over the lower part of Lt. side of chest wall with diminished breath
sounds on the Lt. side, abdominal tenderness and rigidity on the
Lt. hypochondrium. After resuscitation Chest X ray revealed
fractures last Lt. 3 ribs and haemothorax. Abdominal U/S revealed
haematoma surrounding the spleen and free blood in the
abdomen.
Editor's Notes
Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate
Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate
Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures created by outward forces
Lap-belt restraints
“seat belt sign” = contusion or abrasion across the lower abdomen, highly correlated with intraperitoneal injury
eg lap belts herald abdominal injuries in one third of cases
films in which the patient is in a lateral decubitus position, air is located in the superior flank and outlines the lateral liver edge
Demonstration of free intraperitoneal air on left lateral decubitus film. This is the preferred decubitus position because it avoids confusion with the gastric bubble and splenic flexure
Erect film demonstrates the soap bubble appearance of retroperitoneal air outlining the right kidney. Duodenal perforation is the responsible pathologic condition
Grade 4 splenic laceration
Grade 3 right renal laceration (encircled).
CT is particularly helpful in guiding nonoperative management of solid organ damage.[44-46] This includes as-needed follow-up studies of convalescing patients with these injuries. It has also proven effective when incorporated in delayed fashion for patients with decreasing hematocrit, increasing base deficit, or subtle examination changes. By minimizing the incidence of nontherapeutic laparotomies for self-limited injury to the liver or spleen,
trauma centers are using CT with intravenous (IV) contrast only, as it has been shown that little additional information is provided by the addition of oral contrast, which delays scanning and may pose an aspiration risk for the patient.[48,49]
Angioembolization of splenic laceration. Note coil in the splenic artery (white arrow) and blush representing active hemorrhage stemming from two branches
Dependent portions of the intraperiton
when time is precious in the critical patient, the FAST can provide rapid answers to the key question in the decision matrix, which is whether hemoperitoneum is present. Unlike DPL, the FAST can evaluate intrathoracic structures, is noninvasive, and can be performed serially and by multiple technicians. Unlike CT, it is not a potential radiation hazard and does not require administration of contrast agentseal cavity where blood is likely to accumulate
Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow).
Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow).
Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow).
Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
when time is precious in the critical patient, the FAST can provide rapid answers to the key question in the decision matrix, which is whether hemoperitoneum is present. Unlike DPL, the FAST can evaluate intrathoracic structures, is noninvasive, and can be performed serially and by multiple technicians. Unlike CT, it is not a potential radiation hazard and does not require administration of contrast agents
Newer studies advocate adding sonographic contrast to further delineate solid organ injuries with minimal hemoperitoneum, especially those of the spleen and liver, which might be amenable to nonoperative management.[64-66] Overall, US can serve as an accurate, rapid, and less expensive diagnostic screening tool than DPL or CT.[67-70]
GSW Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds
Positive test = specific for intraperitoneal injury
With lower chest stab wounds, a positive RBC count of 5000 to 10,000/mm3 should be considered as evidence of diaphragmatic injury. Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds
(many do not reach the peritoneum)
If LWE indicates that the peritoneum is violated, further diagnostics are indicated. When the stab wound is documented to be superficial to the abdominal cavity, the patient can be safely discharged home after appropriate wound care.[85]
Other areas: like back, flank, chest
This is considered safest in the event that the implement is intravascular or in a highly vascularized organ.The accuracy of physical examination is limited in cases of blunt and penetrating trauma. It is rendered less reliable by distracting injury, altered sensorium (e.g., head trauma, alcohol or drug intoxication, mental retardation), and spinal cord injury.
intestinal perf/spillage can occur afger blunt or PAT
Cover anaerobes
For more extensive abdominal trauma, a central concept is that of damage control
When would you use the damage control strategy? Essentially if the pt is really sick
These are all big topics, about general ICU management but management in the ICU involves:
The best transfusion protocol is debated..
11.2010 NEJM eval of off-label, prospective clinical trials -> increased arterial thromboembolic complications with rfvii
Low tidal volume ventilation- extrapolation from ards studies
Critical care med 2004 retrospective cohort study- found association between the initial tidal volume and the development of acute lung injury suggests that ventilator-associated lung injury may be an important cause of this syndrome
The best transfusion protocol is debated..
Low tidal volume ventilation
Major complication of abdominal trauma
APP = MAP - IAP
Can lead to significant reduced lung volumes, impaired gas exchange, high ventilatory pressures.
